Subscribe To

Wednesday, August 14, 2013

The Nutrition Debate #134: “You Really Don’t Need to Test”

“You really don’t need to
test,” my new doctor, an internist and cardiologist (and PHD!), told me
recently as I was leaving his office. It was only my second visit, and it was
at my suggestion that I will see him
3 times a year instead of once, so I think it was a nice gesture on his part to
give me assurances and comfort that my health in general, and in particular my
type 2 diabetes and hypertension, were “under control.”

He was also telling me that
my other labs, specifically my A1c, blood pressure, and Lipid Panel, all
suggested – to him – that the therapeutic regimens that his predecessor
had ordered and he was continuing, had me in good shape. I got the impression
that seeing me, for him, was a bit of a relief – that most of the patients he
saw on a daily basis were truly sick people. I was “healthy,” by comparison,
and that made his time with me easier for him. He almost seemed, to me, to be
having fun! I liked that. It made me feel good too.

But here’s the rub. He was
telling me that my condition didn’t warrant the level of blood glucose testing
that I had requested he prescribe for me: two times a day. His rationale was
that my A1c, at 5.6% at the time, as it was less than 5.7%, was regarded as a
value consistent with an “Decreased Risk of Diabetes.” This “Reference Range,”
the Quest Diagnostics lab report said, was “supported by the current ‘Standards
of Medical Care in Diabetes’ published in January of the current year in
Diabetes Care, the Journal of the American Diabetes Association.” So, that’s
that. He was ‘covered’ because the ADA says that I am at decreased risk of
diabetes, so ipso facto daily testing
was not warranted. For the new reader, and to remind regulars (and my doctor),
I have been a full-blown, diagnosed type 2 diabetic for 27 years.

Never mind that the report
generated by the blood drawn at that consult showed an increase in my A1c to
5.8%, which is considered consistent with an “Increased Risk of Diabetes.” But
elsewhere in this same report, based on the results of a VAP (TM) Cholesterol
Test that I requested, Quest advised, in response to the question, should the
physician “CONSIDER INSULIN RESIST/METABOLIC SYNDROME,” the response was a flat
“NO.” Never mind that I AM today insulin resistant and, before I changed
my diet, had ALL of the indications of Metabolic Syndrome. See “The
Nutrition Debate #9” for a complete list of the indications and ranges if
you would like to see if YOU have an undiagnosed case of Metabolic
Syndrome.

So, how can all of these
seeming paradoxes coexist? Why is it that my diabetes is no longer discoverable
by a lab test or a clinician’s interpretation? They would be, of course, with a
full medical history, but my new doctor is only acquiring that as he gets to
know me. A good sign: he offered to be added to the email distribution of my
twice-weekly diabetes blog. How cool is that! My previous (now deceased) doctor
also was on the list and occasionally emailed me with comments.

Anyway, I digress. My reason for writing this
post is to make the point that the
patient who has taken control of his diabetes health care, and treats it almost
entirely with diet alone, can achieve these results EVEN IF HE OR SHE IS
INSULIN RESISTANT. When you eat very few carbohydrates, your blood
insulin level goes down, and your insulin sensitivity goes up. Insulin
sensitivity is the inverse of insulin resistance. And importantly, your blood
glucose stabilizes.

A few months ago I asked an
endo in Florida to do a HOMA Assessment to determine my beta cell function and
insulin sensitivity. The results surprised me, since I had been maxed out on a
sulfonylurea for the better part of 20 years. Beta Cell Function: 68.2%.
Sensitivity: 94.6% and IR 1.1 (1.057). I attribute these “good” results to my
Very Low Carb diet.

And when you achieve these
results through strictly eating Very Low Carb, YOUR TYPE 2 DIABETES WILL BE IN
REMISSION. The lab can’t tell that you’re a full-blown type 2 diabetic. Neither
can your doctor, if he doesn’t know your history. But that doesn’t mean you can
rely on the assurances that you’re in “good control” just because you are well
below the thresholds of the American Diabetes Association for being “Consistent
with Diabetes (> or = 6.5). You don’t want to be there. You don’t
want your type 2 diabetes to be a PROGRESSIVE DISEASE, as the ADA defines it.
And by extension your physician will too, if he/she follows the “Standards of
Medical Care in Diabetes, as most will likely do.

YOU can treat yourself
through diet, and the best way to do that is to learn about the carb content of
the foods you eat and how your metabolism handles them. And the only way to do
that is to test.Test before and 1-hour after a suspect
meal. Adjust the menu to meet your goals. Test in the morning before
eating (fasting blood glucose). Test to keep yourself honest - to remind
yourself that you are diabetic and will always be carbohydrate intolerant.
You cannot cure this disease. You can only treat it. And the absolute best
way to treat it is with diet. Vigilance is required. And some discipline.
But the food choices are endless, and very good. As your body adapts to using
ketones, you will have increased physical energy. (See the next column.) You
will feel better. And if you need to lose weight, you can do so easily (with
calorie restriction) and without hunger. What more can you ask?

4 comments:

I was accustomed to having fasting glucose levels between 87-95 on my low carb diet. In the past year, I've gone more paleo, but still with very low carb, and my fasting glucose levels have gone up to between 98-110. I've been really concerned about this. This morning I read on Chris Kesser's site that very low carb diets will produce elevated fasting blood glucose levels. He claims that post-meal blood sugars and A1C levels are more important. Have you had to deal with this? It's pretty scary when you know you've been diligent about your diet and your fasting levels start rising. I can't take metformin, it gave me really bad muscle cramps. I have monitored my blood sugar throughout the day and found that it stays pretty flat, and usually below the first reading. I agree totally with your premise today, do NOT tell diabetics they don't have to test just because it seems everything is under control. I think doctors should all pack a meter with themselves for a week and test before and after meals, just to get an idea what can happen, and what causes things to happen. Their assumptions often have no basis in reality.

I looked briefly at Chris's site but could't find what you are referring to. I do not, frankly, understand what he could possibly mean by "very low carb diets will produce elevated fating blood glucose levels." That doesn't make any sense to me at all.

But you have to remember that Chris is not a very low carb guy. And frankly, to the extent that you are an insuling resistant (carbohydrate intolerant) type 2, as I recall that you are, I don't understand why you would "go more Paleo." See my column #124,"A Lamentable Confusion Between Diets," in which I describe how if you have IR, you really have to do a very limited version of Paleo, or else...your fasting glucose levels will go up. How can it be otherwise?

I agree with Chris, of course, that A1c's and spreads between fasting and postprandial readings are a truer indication of what you are eating, and to that extent they are a much more reliable indication of your status. It is also a much better tool to diagnose type 2s than 2 consecutive FBGs over 126 (diabetic) or 2 consecutive FBGs between 100 and 125 (prediabetic). These were very primitive tools, and of course missed diabetics who ate a VLC diet (like me), instead of a "balanced, healthy diet" with lots of fruits and vegetables (and refined carbs and sugary processed foods), like most of the population.

By "more Paleo" I meant I'm paying more attention to where all that meat I eat comes from. I already gather my own eggs from my own hens, and am lucky to have a vegetable stand practically in my back yard. There's a lot of paleo stuff I can't eat, as a diabetic, or else have to eat in small enough portions that it makes no sense to cook it (sweet potatoes for example). You recall rightly, I am extremely carb intolerant. One thing I am beginning to appreciate about the paleo movement is that it has spread low carb living beyond the diabetic population. When I have dinner with my son and his friends now, they're interested in the same food I eat.

I have only been to Chris' site once, I was following a trail from another site. Thank you for your insight. This is what I was referring to:

"One caveat here is that very low-carb diets will produce elevated fasting blood glucose levels. Why? Because low-carb diets induce insulin resistance. Restricting carbohydrates produces a natural drop in insulin levels, which in turn activates hormone sensitive lipase. Fat tissue is then broken down, and non-esterified fatty acids (a.k.a. "free fatty acids' or NEFA) are released into the bloodstream. These NEFA are taken up by the muscles, which use them as fuel. And since the muscle's needs for fuel has been met, it decreases sensitivity to insulin....So, if you eat a low-carb diet and have borderline high FBG (i.e. 90-105) it may not be cause for concern. Your post-meal blood sugars and A1c levels are more important."

I had never run across this theory in the diabetic world, where higher fasting blood sugars are almost always attributed to the dawn phenomenon and treated with Metformin.

My overall problem has been that no matter how precisely I stick to a low carb and low calorie diet (and I'm very OCD about it), I still gain weight. I'm not giving it up because it works well for my blood sugar, but I still need to find a key for the weight problem. In the past couple of years I've gained 30 pounds. It's very depressing and sooner or later I know my blood sugar and other blood tests will suffer.

As you know, we're mostly on this journey outside the guidance of the traditional medical world, so I always appreciate the things I glean from your writing.

'More Paleo'in the sense you clarified is fantastic. I wish I could get my wife to agree to buy, or let me buy, grass-fed, grass-finished beef, etc. She doesn't like it, even sausages from local producers that are packed nearby. She says they're 'dry.'

I agree with you and not with Chris. My own experience is that lower serum insulin has made my cells MORE insulin sensitive. I attribute my relatively high insulin sensitivity to my VLC diet. See my HOMA test results in #86.

I also have a different understanding (than yours) about DP. I don't know what causes some people's hormones to jump start glucose in the morning, but my understanding is that Metformin is used primarily to suppress unwanted manufacture of glucose from excess amino acids stored in the liver from eating 'too much' protein, i.e., what the cells can 'take up' in 4 to 5 hours after the protein is broken down to amino acids through digestion. I did not associate this unwanted glucose production with DP. I do take my 500MG of Metformin with dinner, though, since that is the only meal in which I am unlikely to overeat protein. I have about 20g for breakfast and 15g for lunch. In the best of all worlds I would only have 20g at dinner (55g total),but I sometimes eat more. Last night, I had just one chicken thigh instead of the two I used to eat, plus young green beans bathed in butter.

Thanks, Jan. You're very kind to say such nice things about me. I would advise you though to read many sources and bloggers. They are copious. A new one I get emails from is Authority Nutrition. He is pithy, gives links to all his dogma, and pretty much follows the straight and narrow. I could nit pic and quibble on a few points, but he's good. Also, check out the Diet Doctor, Andreas Eenfeldt. He's another good one.

About Me

I was diagnosed a Type 2 diabetic in 1986. I started a Very Low Carb diet (Atkins Induction) in 2002 to lose weight. I didn’t realize at the time that it would put my diabetes in clinical remission, or that I would be able to give up almost all of my oral diabetes meds. I also didn’t understand that, as I lost weight and continued to eat Very Low Carb, my blood lipids would dramatically improve (doubling my HDL and cutting my triglycerides by 2/3rds) and that my blood pressure would drop from 130/90 to 110/70 on the same meds.
Over the years I changed from Atkins to the Bernstein Diet (designed for diabetics) and, altogether lost 170 pounds. I later regained some and then lost some. As long as I eat Very Low Carb, I am not hungry and I have lots of energy. And I no longer have any of the indications of Metabolic Syndrome.
My goal, as long as I have excess body fat, is to remain continuously in a ketogenic state, both for blood glucose regulation and continued weight loss. I expect that this regimen will continue to provide the benefits of reduced systemic inflammation, improved blood lipids and lower blood pressure as well.